Exam 1: Respiratory: COPD
The 85-year-old client diagnosed with severe end-stage chronic obstructive pulmonary disease has a chest x-ray that incidentally reveals an eight (8)-cm abdominal aortic aneurysm. Which intervention should the nurse implement? 1. Discuss possible end-of-life care issues. 2. Prepare the client for abdominal surgery. 3. Teach the client how to pursed-lip breathe. 4. Talk with the family about the client's condition.
. 1. The client with end-stage COPD would not be a candidate for an AAA repair, although the size of the aneurysm places the client at risk for rupture. Although many nurses do not like to address end-of life issues, this would be an important and timely intervention.
The nurse is caring for the client diagnosed with COPD. Which outcome requires a revision in the plan of care? 1. The client has no signs of respiratory distress. 2. The client shows an improved respiratory pattern. 3. The client demonstrates intolerance to activity. 4. The client participates in establishing goals.
3. The client demonstrates intolerance to activity. Rationale: The expected outcome should be that the client has tolerance for activity; because the client is not meeting the expected outcome, the plan of care needs revision. Why it's not the rest: The expected outcome showing no signs of respiratory distress indicates the plan of care is effective and should be continued. An improved respiratory pattern indicates the plan should be continued. The client should participate in planning the course of care; the client is meeting the expected outcome.
An elderly male client with newly diagnosed end-stage chronic obstructive pulmonary disease (COPD) is being discharged to home. The client's wife is his sole caregiver. The client is unable to provide self-care and requires continuous assistance. Which service would provide the greatest assistance to the client's wife? 1. Skilled nursing care 2. Respite care 3. Hospice care 4. Physical therapy
ANSWER: 2 Respite care is the service that provides relief care for family caregivers. Skilled nursing care and physical therapy would provide direct care for the client but not the client's caregiver. Hospice care provides end-of-life services for both the client and family. Test-taking Tip: The key words are "greatest assistance to the client's wife." Read the question thoroughly so that you do not miss any information.
The nurse and unlicensed nursing assistant are caring for a group of clients on a surgical floor. Which information provided by the nursing assistant requires immediate intervention by the nurse?
The most serious complication resulting from a radical neck dissection is rupture of the carotid artery. A continuous bright-red drainage indicates bleeding, and this client should be assessed immediately.
Which statement made by the client indicates the nurse's discharge teaching is effective for the client diagnosed with COPD? 1. "I need to get an influenza vaccine each year, even when there is a shortage." 2. "I need to get a vaccine for pneumonia each year with my influenza vaccine." 3. "If I reduce my cigarettes to six (6) a day, I won't have difficulty breathing." 4. "I need to restrict my drinking liquids to keep from having so much phlegm."
1. "I need to get an influenza vaccine each year, even when there is a shortage." Rationale: Clients diagnosed with COPD should receive the influenza vaccine each year. If there is a shortage, these clients have top priority. Why it's not the rest: The pneumococcal vaccine should be administered every five (5) to seven (7) years. Reducing the number of cigarettes smoked does not stop the progression of COPD, and the client will continue to experience signs and symptoms such as SOB or dyspnea on exertion. Clients diagnosed with COPD should increase their fluid intake unless contraindicated for another health condition; the increased fluid assists the client in expectorating the thick sputum.
The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse? 1. The client's pulse oximeter reading is 92%. 2. The client's arterial blood gas level is 74. 3. The client has SOB when walking to the bathroom. 4. The client's sputum is rusty colored.
1. 4. The client's sputum is rusty colored. Rationale: Rusty-colored sputum indicates blood in the sputum and requires further assessment by the nurse. Why it's not the rest: The client with end-stage COPD has decreased peripheral O2 levels. The client's ABGs would normally indicate a low O2 level. The client who develops dyspnea on exertion should stop the exertion but does not require intervention by the nurse if the dyspnea resolves.
The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first? 1. Assist the client into a sitting position at 90 degrees. 2. Administer oxygen at six (6) LPM via nasal cannula. 3. Monitor vital signs with the client sitting upright. 4. Notify the health care provider about the client's status.
1. Assist the client into a sitting position at 90 degrees. Rationale: The client should be assisted into a sitting position either on the side of the bed or in the bed. This position decreases the work of breathing. Some clients find it easier sitting on the side of the bed leaning over the bed table. The nurse needs to maintain the client's safety. Why it's not the rest: O2 will be applied as soon as possible, but the least amount possible; if levels are too high, the client might stop breathing. VS need to be monitored, but are not priority. The HCP needs to be notified, but the client must be treated first; the nurse should get assistance if possible so the nurse can treat this client quickly.
Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply. 1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition.
1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition. Rationale: The client diagnosed with COPD has difficulty exchanging O2 with CO2, which is manifested by physical signs such as fingernail clubbing and respiratory acidosis as seen on ABGs. The client should avoid extremes in temperatures. Warm temperatures cause an increase in the metabolism and increase the need for O2. Cold temperatures cause bronchospasms. The client has increased respiratory effort during activities and can be fatigued. Activities should be timed so rest periods are scheduled to prevent fatigue. The client may have difficulty adapting to the role changes brought about because of the disease process. Many cannot maintain the activities involved in the meeting responsibilities at home and at work. Clients should be assessed for these issues. Clients often lose weight because of the effort expended to breathe. Why it's not the rest: N/A.
The most serious complication resulting from a radical neck dissection is rupture of the carotid artery. A continuous bright-red drainage indicates bleeding, and this client should be assessed immediately.
1. Normal mean pulmonary artery pressure is about 15 mm Hg and an elevation indicates right ventricular heart failure or cor pulmonale, which occurs in chronic obstructive pulmonary disease. The nurse should question this order because this rate is too high and sodium should be restricted.
Which outcome is appropriate for the client problem "ineffective gas exchange" for the client recently diagnosed with COPD? 1. The client demonstrates the correct way to pursed-lip breathe. 2. The client lists three (3) signs/symptoms to report to the HCP. 3. The client will drink at least 2,500 mL of water daily. 4. The client will be able to ambulate 100 feet with dyspnea.
1. The client demonstrates the correct way to pursed-lip breathe. Rationale: Pursed-lip breathing helps keep the alveoli open to allow for better O2 and CO2 exchange. Why it's not the rest: Outcome 2 is appropriate for a knowledge-deficit problem. Outcome 3 does not ensure the client has an effective airway; increasing fluid does not ensure an effective airway. Outcome 4 is not appropriate for any client problem because the client should be able to ambulate w/o dyspnea for 100 feet.
The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? 1. Large amounts of thick white sputum. 2. Oxygen flowmeter set on eight (8) liters. 3. Use of accessory muscles during inspiration. 4. Presence of a barrel chest and dyspnea.
2. Oxygen flowmeter set on eight (8) liters. Rationale: The nurse should decrease the O2 rate to two (2) or three (3) liters. Hypoxemia is the stimulus for breathing in the client with COPD. If the hypoxemia improves and the O2 level increases, the drive to breathe may be eliminated. Why it's not the rest: A large amount of thick sputum in a common symptom of COPD. It is common for COPD clients to use accessory muscles when inhaling. Clients with COPD commonly have the characteristic barrel chest from chronic hyperinflation and dyspnea.
The nurse observes the UAP removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the nurse implement? 1. Praise the UAP because the prevents the client from tripping on the oxygen tubing. 2. Place the oxygen back on the client while sitting in the bathroom and say nothing. 3. Explain to the UAP in front of the client oxygen must be left in place at all times. 4. Discuss the UAP's action with the charge nurse so appropriate action can be taken.
2. Place the oxygen back on the client while sitting in the bathroom and say nothing. Rationale: The client needs the O2, and the nurse should not correct the UAP in front of the client; it is embarrassing for the UAP and the client loses confidence in the staff. Why it's not the rest: The client with COPD needs O2 at all times, especially when exerting energy such as ambulating to the bathroom. The nurse should not verbally correct a UAP in front of the client; the nurse should correct the behavior and then talk to the UAP in private. The primary nurse should confront the UAP and take care of the situation; continued unsafe client care would warrant notifying the charge nurse.
Which clinical manifestation should the nurse expect to assess in the client recently diagnosed with COPD? 1. Clubbing of the client's fingers. 2. Infrequent respiratory infections. 3. Chronic sputum production. 4. Nonproductive hacking cough.
3. Chronic sputum production. Rationale: Sputum production, along with cough and dyspnea on exertion, are the early signs/symptoms of COPD. Why it's not the rest: Clubbing of fingers is the result of chronic hypoxemia, which is expected with chronic COPD but not recently diagnosed COPD. COPD clients have frequent respiratory infections. These clients have a productive cough, not a nonproductive cough.
Which referral is most appropriate for a client diagnosed with end-stage COPD? 1. The Asthma Foundation of America. 2. The American Cancer Society. 3. The American Lung Association. 4. The American Heart Association.
3. The American Lung Association. Rationale: The American Lung Association has information helpful for a client with COPD. Why it's not the rest? The other options may have information useful for other clients, but none have information about COPD available for COPD clients.
The client diagnosed with acute pancreatitis is in pain. Which position should the nurse assist the client to assume to help decrease the pain? 1. Recommend lying in the prone position with legs extended. 2. Maintain a tripod position over the bedside table. 3. Place in side-lying position with knees flexed. 4. Encourage a supine position with a pillow under the knees.
3. This fetal position decreases pain caused by stretching of the peritoneum as a result of edema.
The client diagnosed with chronic obstructive pulmonary disease is being discharged and is prescribed the steroid prednisone. Which scientific rationale supports why the nurse instructs the client to taper off the medication? 1. The pituitary gland must adjust to the decreasing dose. 2. The beta cells of the pancreas have to start secreting insulin. 3. This will allow the adrenal gland time to start to function. 4. The thyroid gland will have to start producing cortisol.
3. When the client is receiving exogenous steroids, the adrenal glands stop producing cortisol, and if the medication is not tapered, the client can have a severe hypotensive crisis, known as adrenal gland insufficiency or Addisonian crisis.
Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required? 1. "I should contact my health care provider if my sputum changes color or amount." 2. "I will take my bronchodilator regularly to prevent having bronchospasms." 3. "This metered-dose inhaler gives a precise amount of medication with each dose." 4. "I need to return to the HCP to have my blood drawn with my annual physical."
4. "I need to return to the HCP to have my blood drawn with my annual physical." Rationale: Clients should have blood levels drawn every six (6) months when taking bronchodilators, not yearly. This indicates the client needs more teaching. Why it's not the rest: When sputum changes color or amount, or both, this indicates infection, and the client should report this information to the HCP. Bronchodilators should be taken routinely to prevent bronchospasms. Clients use metered-dose inhalers because they deliver a precise amount of medication with correct use.
The nurse is assessing the client with COPD. Which health promotion information is most important for the nurse to obtain? 1. Number of years the client has smoked. 2. Risk factors for complications. 3. Ability to administer inhaled medications. 4. Willingness to modify lifestyle.
4. Willingness to modify lifestyle. Rationale: The client's attitude toward lifestyle changes is the most important consideration in health promotion, in this case smoking cessation. The nurse should assess if the client is willing to consider cessation of smoking and carry out the plan. Why it's not the rest: The number of years of smoking is information needed to treat the client but not most important. The risk factor for complications are important for planning care. Assessing the ability to deliver medications is an important consideration when teaching the client.
.Which actions should be taken by a nurse when caring for a client who is experiencing dyspnea due to heart failure and chronic obstructive pulmonary disease (COPD)? SELECT ALL THAT APPLY. Apply oxygen 6 liters per nasal cannula Elevate the head of the bed 30 to 40 degrees Weigh the client daily in the morning Teach the client pursed-lip breathing techniques Turn and reposition the client every 1 to 2 hours
ANSWER: 2, 3, 4 Elevating the head of the bed will promote lung expansion. Daily weights will assess fluid retention. Fluid volume excess can increase dyspnea and cause pulmonary edema. Pursed-lip breathing techniques allow the client to conserve energy and slow the breathing rate. Options 1 and 5 are incorrect actions. Applying greater than 4 liters of oxygen per nasal cannula is contraindicated for COPD. High flow rates can depress the hypoxic drive. Because the client with COPD suffers from chronically high CO2 levels, the stimulus to breathe is the low O2 level (a hypoxic drive). The situation does not warrant turning the client every 1 to 2 hours. This activity could increase the client's energy expenditure and dyspnea. Test-taking Tip: A multiple-response item requires selecting all of the options that relate to the information provided in the question. Focus on the client's dyspnea and the interventions applicable to both heart failure and COPD
A client with chronic obstructive pulmonary disease (COPD) is in the third postoperative day following right-sided thoracotomy. During the day shift, the client has required 10 L oxygen by mask to keep his or her oxygen saturations greater than 88%. Based on this information, which action should be taken by the evening shift nurse? 1. Work to wean oxygen down to 3 L by mask 2. Call respiratory therapy for a nebulizer treatment 3. Check respiratory rate and notify the physician 4. Administer dose of ordered pain medications
ANSWER: 3 The night shift nurse should check the client's respiratory rate and report abnormal findings to the physician. Although uncommon, clients with COPD on high flow oxygen can lose their respiratory drive. Working to wean down oxygen by mask below 3 L will cause retention of CO2; oxygen by mask generally should be set at 4 L or greater. Although a nebulizer and pain medications may assist the client, the immediate need is to determine if the high flow oxygen is affecting the client's respiratory drive and to further determine the cause of the low oxygen saturations. Test-taking Tip: An option that includes an assessment is often the correct answer because the nursing process is driven by the information collected in an assessment.
A client learning about chronic obstructive pulmonary disease self-care at a community health class, asks a nurse why the participants are being taught about the "lip-breathing." The nurse should respond by explaining that pursed-lip breathing can help to: 1. reduce upper airway inflammation. 2. reduce anxiety through humor. 3. strengthen respiratory muscles. 4. increase effectiveness of inhaled medications.
ANSWER: 3 Pursed-lip breathing increases the strength of respiratory muscles and helps to keep alveoli open. It does not have an affect on upper airway inflammation, provide humor therapy, and is not a part of medication administration.
. A nurse reviews the plan of care for an elderly client diagnosed with chronic obstructive pulmonary disease (COPD) and limited mobility. The nurse notes that the physical therapist has indicated a change in the plan of care to progress ambulation from 100 to 200 feet twice a day. Which action is necessary to ensure that the client's needs are met? 1. Instructing the physical therapist not to ambulate the client without the nurse present 2. Informing the physical therapist of the client's respiratory status prior to progressing ambulation 3. Cancelling the physical therapy referral 4. Informing the physician about the physical therapist's plan to progress ambulation
Collaborating with other health-care professionals is crucial for facilitating outcome attainment. Using an interdisciplinary approach to meet the client's needs will expedite recovery. The nurse is responsible for overseeing the client's care. Therefore the nurse should inform the physical therapist of the client's respiratory status. The importance of communication regarding the respiratory status of the patient and a discussion of an alteration in the plan of care would be necessary to meet the needs of the client. The physical therapist may independently ambulate the client; however, the nurse may want to give instructions such as "stop ambulation if the respiratory rate exceeds 30 beats per minute." The physical therapy referral should not be cancelled as the client needs assistance in progressing ambulation. Although it would have been preferable for the physical therapist to tell the nurse about the plan to progress ambulation, the plan of care reflects the change; it is unnecessary to notify the physician. Test-taking Tip: The key phrases are "which action is necessary" and "to meet the needs of the client." Focus on the respiratory status of the client and the responsible person for the overall care of the client.
The unlicensed nursing assistant notifies the nurse that the client diagnosed with chronic obstructive pulmonary disease is complaining of shortness of breath and would like his oxygen level increased. Which action should the nurse implement?
The oxygen level for a client with COPD must remain between 2 and 3 L/min because the client's stimulus for breathing is low blood oxygen levels. If the client receives increased oxygen, the stimulus for breathing will be removed and the client will stop breathing.
